PHYSICAL EXAMINATION - HEALTH HISTORY
EXAM QUESTIONS & ANSWERS
What is a Comprehensive Health History (CHH) and when is it best used? - ANS-A comprehensive
interview to gather all aspects of the patient's history
For use with a new patient
What is a Focused History and when is it best used? - ANS-A problem-orientated history that is more
limited and tailored to a specific problem
For use with an established patient
What are the five steps of the nursing process? - ANS-1. Assessment
2. Outcome Identification
3. Planning
4. Implementation
5. Evaluation
In a successful interview you... - ANS-1. generate the patient's story and gather complete and accurate
data about the patient
2. Establish rapport and trust
3. Build a continuing therapeutic relationship
4. Teach about the health state, health promotion and disease prevention.
What is patient centered care?
(Institute of Medicine definition) - ANS-Respecting and responding to patients' wants, needs, and
preferences, so they can make choices in their care that best fit their individual circumstances.
Setting the Environment for a patient interview - what is important? - ANS-Courtesy and Comfort
1. Privacy - Knock on the door, use privacy curtains, be aware of room-mates (inquire about
confidentiality wishes)
2. Attention/lack of interruptions - ask for coverage help to ensure you give the patient your full
attention
3. Comfortable room - make sure room is clean and at adequate temperature
4. Seating - provide comfortable seating for the patient, sit at equal level with the patient, do not place
furniture between you and the patient.
5. Dress - Understand and be empathetic to patient vulnerability in gowns. Wear proper uniform
(provides patient with professional image and establishes non-verbal recognition of care).
, 6. Note taking/use of computer during the interview at minimum - explain why you are taking notes or
using a computer, involve patient if possible.
What is involved in effective communication for skilled interviewing? - ANS-1. Active Listening
2. Empathetic responses - non-verbal and verbal, be open and genuine, pay attention to patient body
language and cues
3. Guided questioning - ask open-ended questions, pause between questions, give multiple choices if
needed
4. Non-verbal communication - maintain professionalism in all patient answers
5. Validation & Reassurance - do not say "you will be ok" and avoid false reassurance
6. Partnering - let the patient know we are not going to abandon them
7. Summarize - gives clarity to the interaction, allows patient to provide input if anything is inaccurate or
missing.
8. Use transitions
9. Empowering the patient - ask what the patient wants, goals
What does OLDCARTS stand for? - ANS-O - onset
L - Location
D - Duration
C - Character
A - Aggrivating/Alleviating Factors
R - Radiation
T - Timing
S - summary
What does OPQRST stand for? - ANS-O - Onset
P - Palliating/Provoking Factors
Q - Quality
R - Radiating
S - Site
T - Timing
What are the seven attributes of a symptom - ANS-1. Location - where is it? does it radiate?
2. Quality - what is it like?
3. Quantity or severity - how bad is it? (for pain, 1-10 raiting)
4. Timing - when did (does) it start? How long does it last? How often does it come?
5. Setting in which it occurs - include environmental factors, personal activities, emotional reactions, or
other circumstances that may have contributed to the illness
6. Remitting or exacerbating factors - is there anything that makes it better or worse?
7. Associated manifestations - have you noticed anything else that accompanies it?
Exploring the patients perspective - understand what are the patients... - ANS-1. Feelings about the
problem
2. Ideas about the nature and cause of the problem
3. Functional changes and effect on the patient's life
4. Expectations of the disease, clinician, or of health care.
Responding to a patients emotions - you... - ANS-1. Name the emotion (it appears to me that...)
EXAM QUESTIONS & ANSWERS
What is a Comprehensive Health History (CHH) and when is it best used? - ANS-A comprehensive
interview to gather all aspects of the patient's history
For use with a new patient
What is a Focused History and when is it best used? - ANS-A problem-orientated history that is more
limited and tailored to a specific problem
For use with an established patient
What are the five steps of the nursing process? - ANS-1. Assessment
2. Outcome Identification
3. Planning
4. Implementation
5. Evaluation
In a successful interview you... - ANS-1. generate the patient's story and gather complete and accurate
data about the patient
2. Establish rapport and trust
3. Build a continuing therapeutic relationship
4. Teach about the health state, health promotion and disease prevention.
What is patient centered care?
(Institute of Medicine definition) - ANS-Respecting and responding to patients' wants, needs, and
preferences, so they can make choices in their care that best fit their individual circumstances.
Setting the Environment for a patient interview - what is important? - ANS-Courtesy and Comfort
1. Privacy - Knock on the door, use privacy curtains, be aware of room-mates (inquire about
confidentiality wishes)
2. Attention/lack of interruptions - ask for coverage help to ensure you give the patient your full
attention
3. Comfortable room - make sure room is clean and at adequate temperature
4. Seating - provide comfortable seating for the patient, sit at equal level with the patient, do not place
furniture between you and the patient.
5. Dress - Understand and be empathetic to patient vulnerability in gowns. Wear proper uniform
(provides patient with professional image and establishes non-verbal recognition of care).
, 6. Note taking/use of computer during the interview at minimum - explain why you are taking notes or
using a computer, involve patient if possible.
What is involved in effective communication for skilled interviewing? - ANS-1. Active Listening
2. Empathetic responses - non-verbal and verbal, be open and genuine, pay attention to patient body
language and cues
3. Guided questioning - ask open-ended questions, pause between questions, give multiple choices if
needed
4. Non-verbal communication - maintain professionalism in all patient answers
5. Validation & Reassurance - do not say "you will be ok" and avoid false reassurance
6. Partnering - let the patient know we are not going to abandon them
7. Summarize - gives clarity to the interaction, allows patient to provide input if anything is inaccurate or
missing.
8. Use transitions
9. Empowering the patient - ask what the patient wants, goals
What does OLDCARTS stand for? - ANS-O - onset
L - Location
D - Duration
C - Character
A - Aggrivating/Alleviating Factors
R - Radiation
T - Timing
S - summary
What does OPQRST stand for? - ANS-O - Onset
P - Palliating/Provoking Factors
Q - Quality
R - Radiating
S - Site
T - Timing
What are the seven attributes of a symptom - ANS-1. Location - where is it? does it radiate?
2. Quality - what is it like?
3. Quantity or severity - how bad is it? (for pain, 1-10 raiting)
4. Timing - when did (does) it start? How long does it last? How often does it come?
5. Setting in which it occurs - include environmental factors, personal activities, emotional reactions, or
other circumstances that may have contributed to the illness
6. Remitting or exacerbating factors - is there anything that makes it better or worse?
7. Associated manifestations - have you noticed anything else that accompanies it?
Exploring the patients perspective - understand what are the patients... - ANS-1. Feelings about the
problem
2. Ideas about the nature and cause of the problem
3. Functional changes and effect on the patient's life
4. Expectations of the disease, clinician, or of health care.
Responding to a patients emotions - you... - ANS-1. Name the emotion (it appears to me that...)
